Hypertension 1 + 2 Flashcards
What was revealed about cardiovascular risk with regards to hypertension in the Framingham study? (2)
- In men, hypertension increased risk for CHD twofold, and risk for stroke and HF fourfold
- In women, hypertension increased risk for CHD twofold, and risk for stroke and heart failure threefold
What is the relationship between CV mortality and hypertension?
CV disease mortality risk doubles with each 20/10 (systolic/diastolic) mmHg BP increase
What percentage of hypertensives have additional risk factors? Examples?
- 80%
* e.g. diabetes, dyslipiaemia
Definition of hypertension?
Level of BP where treatment does more good than harm
Recommendations for measuring BP?
Relaxed, temperate setting with patient quiet and seated
How is diagnosis of hypertension confirmed in patient with BP 140/90 mmHg?
Ambulatory blood pressure monitoring (ABPM)
What must be done if using ABPM to confirm diagnosis of hypertension? HBPM?
- ABPM - at least two measurements per hour during person’s usual waking hours (usually 14/day)
- HBPM - two consecutive seated measurements, 1 minute apart
- BP recorded twice a day for at least 4 days
- Measurements on the first day are discarded –
average value of all remaining is used
What is stage 1 hypertension? Stage 2? Severe hypertension?
- Stage 1 - clinic BP is 140/90mmHg or higher AND ABPM or HBPM daytime average is 135/85mmHg or higher
- Stage 2 - Clinic BP 160/100mmHg or higher AND ABPM or HBPM daytime average is 150/95mmHg
or higher - Severe - clinic systolic BP is 180mmHg or higher OR
clinic diastolic BP is 110mmHg or higher
What does high clinic BP but low ambulatory pressure mean? High ambulatory pressure but low clinic? High clinic pressure and ambulatory pressure? Low clinic pressure and low adulatory pressure?
- White coat hypertension
- Masked hypertension (“black coat hypertension) 10-20% of patients
- Sustained hypertension
- True normotension
Rank sustained hypertension, white coat hypertension, normotension and masked hypertension in order of incidence of cardiovascular events (4)
- Sustained hypertension (highest)
- Masked hypertension
- White coat hypertension
- Normotension (lowest)
What are recommendations for assessing cardiovascular risk and target organ damage? (4)
For those with hypertension
- test urine for presence of protein
- measure blood glucose, electrolytes, creatine, glomerular filtration rate and cholesterol
- examine funds for hypertensive retinopathy
- 12-lead ECG
What is the main driver of absolute risk for hypertension?
Age
End organ damage from hypertension?
- Left Ventricular Hypertrophy
- Creatinine Raised
- Albuminuria / microalbuminuria
- Retinopathy
What are forms of established vascular disease?
- Ischaemic Heart Disease
- Cerbro-Vascular Diseased
- Peripheral Vascular Disease
- Diabetes
What are the classifications of hypertensive retinopathy? (4)
- Grade I - slight or modest narrowing or retinal arterioles with atriovenous ratio >1:2
- Grade II - modest to severe narrowing of retinal arterioles with atriovenous ratio <1:2 or atriovenous nicking
- Grade III - bilateral soft exudates or flame-shaped haemorrhages
- Grade IV - bilateral optic nerve oedema
What are signs of hypertensive retinopathy in funduscopy (ophthalmoscopy)? (3)
- Haemorrhage
- Hard exudates
- Blurred disk
What are signs of grade 4 hypertensive retinopathy in funduscopy? (4) What should be done if a patient has these signs?
- Flame haemorrhage
- Papilloedema
- Cotton wool spot
- Hard exudates
Hospitalised
What is the appearance of LVH on ECG?
ST depression
What is the care for stage 1 hypertension? (3)
What about if end organ damage is present or they have 10 year cardiovascular risk >20%? What if they are younger than 40 years?
- Lifestyle interventions
- Patient education
- Annual review to monitor blood pressure, provide support and sinus lifestyle, symptoms and medication
- Antihypertensive drug treatment
- Consider specialist referral
What is the care for stage 2 hypertension?
Antihypertensive drug treatment
What should an ACE-I not be combined with?
ARBs
In what groups of people are calcium channel blockers given instead of ACEI/ARBs? (2) What drugs are given if there is evidence of heart failure or high risk of heart failure?
- Over 55 y/o
- Black people of African or Caribbean origin
- Thiazide-like diuretic
What is target clinic BP for people aged 80 and over? HBPM BP?
- Less than 150/90 mmHg
* Less than 145//85 mmHg
What did SPRINT trials show?
Intensive treatment resulted in lower CV risk than standard treatment as greater decrease in systolic BP
Significance of twin studies with essential hypertension?
Show 30-50% of BP variability genetically determined
Factors contributing to high BP? (6)
- Cholesterol
- Triglycerides
- Insulin
- Hematocrit
- BMI
- Heart rate
What is the importance of BP in reducing risk of stroke and CHD?
- Decrease in DBP by 5mmHg results in 40% decrease in stroke risk and 25% decrease in CHD
Common causes of secondary hypertension? (4)
- Renal disease
- Obstructive sleep apnoea
- Aldosteronism
- Reno-vascular disease
Uncommon causes of secondary hypertension? (5)
- Cushing’s
- Pheochromocytoma
- Hyperparathyroidism
- Aortic coarctation
- Intracranial tumour
How does obstructive sleep apnoea cause secondary hypertension?
Constant stimulation of sympathetic system during the night eventually resets BP to higher level
What is polycystic kidney disease?
Genetic cause of hypertension
What percentage of hypertensive patients have inappropriate secretion of aldosterone?
60%
Symptoms of pheochromocytoma? (3) How is it contracted? Cure?
- Tachycardia
- Pale
- Episodic high BP
Genetically inherited but curable by surgery
Renal artery stenosis? Treatment?
- Renal artery does not feed kidney properly so hypotension of renal artery resulting in raised BP
- Angioplasy and stenting
Why is revascularisation seldom used as treatment for renal artery stenosis?
No benefit and substantial risk
What is fibromuscular dysplasia?
Curable form of hypertension in young women, corkscrew abnormality fixed with angioplasty
Lifestyle interventions for hypertension?
- Diet
- Alcohol consumption
- Smoking
Benefit of weight loss in hypertension?
1 mmHg for every kg lost
Minimum amount of physical activity a day for reduced hypertension mortality? (2)
- 15 min/day - 14% reduced mortality
* Every extra 15 min/day - extra 4% reduced mortality
Benefit of reduced salt intake in hypertension? (2)
- No added salt diet = reduce BP 2-4 mmHg
* Long term sodium reduction may also reduce long term risk of CV events
Is there benefit of calcium, magnesium, potassium or combination supplements in hypertension?
No evidence of BP benefit
Benefit of DASH diet?
- Reduced BP in hypertensives (11.4/5.5 mmHg reduction)
* Lowest blood BP = lowest sodium intake
Benefit of aerobic exercise?
Aerobic exercise reduces blood pressure 3.8/2.6mmHg
Relative and absolute risk reduction in hypertension?
Lowering BP/cholesterol has same relative risk reduction but different absolute risk
Difference in reduction of BP and thus CV event between chlorthalidone (thiazide diuretic), amlodipine (Ca++ blocker) and lisinopril (ACE-I)?
Identical in lowering BP and CV risk
What are the beneficial effects of antihypertensive therapies due to?
BP lowering
Benefits of antihypertensive drugs? (4)
- Effect is the same across BP ranges
- All age groups
- Systolic and diastolic hypertension
- All levels of CV risk
Drugs used in treatment of hypertension? (6)
- Thiazide diuretics
- ACE-Is/ARBS
- Ca++ channel blockers
- B-blockers
- Spironalactone (diuretic)
- Alpha blockers
Targeted treatment of antihypertensive drugs?
- Thiazide diuretics - elderly
- ACE-Is/ARBS - CCF and diabetic nephropathy
- Ca++ channel blockers - angina
- B-blockers - CCF and angina
- Alpha blockers - prostatism
Antihypertensive drug treatment in individual aged under 55 years? Resistant hypertension?
- Step 1 - ACE-I or ARB
- Step 2 - ACE-I/ARB + CCB
- Step 3 - ACEI/ARB + CCB _ thiazide-like diuretic
- Step 4 (Resistant hypertension) - ACEI/ARBS + CCB + thiazide-like diuretic + alpha or beta-blocker
Antihypertensive drug treatment in individual aged over 55 years or black person of African or Caribbean origin?
- Step 1 -CCB
- Step 2 - ACE-I/ARB + CCB
- Step 3 - ACEI/ARB + CCB _ thiazide-like diuretic
- Step 4 (Resistant hypertension) - ACEI/ARBS + CCB + thiazide-like diuretic + alpha or beta-blocker
Does protection with drug classes vary with age?
No strong evidence that protection with drug classes varies with age
Why are ARBs often favoured over ACEIs?
Fewer side effects than placebo (no dry cough)
In hypertension, should drugs be added or titrated?
Adding a drug
5 x more effective
than titrating
Is combination therapy or mono therapy used in hypertension?
Combination therapy - has fewer side effects than mono-therapy
What treatment is given to those with drug intolerance?
Multiple low dose drugs
What are “causes” of resistant hypertension? (7)
- Non-concordance
- White coat effect
- Pseudo-hypertension
- Lifestyle factors
- Drug interactions
- Secondary hypertension
- True resistance
What is resistant hypertension?
Drug treatment fails to lower BP
What is spironolactone? What is significant about spironolactone?
- 4th line diuretic drug used in treatment of hypertension
* Most effective treatment for resistant hypertension
When should spironolactone be used with caution?
In patients with diabetes and low glomerular filtration rate
New technology for hypertension? (3)
- Renal denervation
- Baro-receptor stimulation
- ROX coupler
Is renal after denervation effective treatment for hypertension? Carotid baroreceptor stimulation? ROX coupler?
- No, no reduction of BP in sham control
- Yes but must wear device continuously and have carotid barorecpetor coninuously stimulated
- Uncontrolled trial so unsure
What is ROX procedure?
Central arteriovenous anastomosis for patients with uncontrolled hypertension
